Initial empirical treatment regimens for community acquired pneumonia (CAP) in adults
| Pneumonia severity (based on clinical judgement supported by CURB65 severity score) | Treatment site | Preferred treatment | Alternative treatment |
| Low severity (eg, CURB65 = 0–1 or CRB65 score = 0, <3% mortality) | Home | Amoxicillin 500 mg tds orally | Doxycycline 200 mg loading dose then 100 mg orally or clarithromycin 500 mg bd orally |
| Low severity (eg, CURB65 = 0–1,<3% mortality) but admission indicated for reasons other than pneumonia severity (eg, social reasons/unstable comorbid illness) | Hospital | Amoxicillin 500 mg tds orallyIf oral administration not possible: amoxicillin 500 mg tds IV | Doxycycline 200 mg loading dose then 100 mg od orally or clarithromycin 500 mg bd orally |
| Moderate severity (eg, CURB65 = 2, 9% mortality) | Hospital | Amoxicillin 500 mg –1.0 g tds orally plus clarithromycin 500 mg bd orallyIf oral administration not possible: amoxicillin 500 mg tds IV or benzylpenicillin 1.2 g qds IV plus clarithromycin 500 mg bd IV | Doxycycine 200 mg loading dose then 100 mg orally or levofloxacin 500 mg od orally or moxifloxacin 400 mg od orally* |
| High severity (eg, CURB65 = 3–5, 15–40% mortality) | Hospital (consider critical care review) | Antibiotics given as soon as possibleCo-amoxiclav 1.2 g tds IV plus clarithromycin 500 mg bd IV(If legionella strongly suspected, consider adding levofloxacin†) | Benzylpenicillin 1.2 g qds IV plus either levofloxacin 500 mg bd IV or ciprofloxacin 400 mg bd IVORCefuroxime 1.5 g tds IV or cefotaxime 1 g tds IV or ceftriaxone 2 g od IV, plus clarithromycin 500 mg bd IV(If legionella strongly suspected, consider adding levofloxacin†) |
bd, twice daily; IV, intravenous; od, once daily; qds, four times daily; tds, three times daily.
*Following reports of an increased risk of adverse hepatic reactions associated with oral moxifloxacin, in October 2008 the European Medicines Agency (EMEA) recommended that moxifloxacin “should be used only when it is considered inappropriate to use antibacterial agents that are commonly recommended for the initial treatment of this infection”.
†Caution – risk of QT prolongation with macrolide-quinolone combination.